Is a targeted and planned GP intervention effective in cardiovascular disease prevention? A randomized controlled trial.

BACKGROUND: The optimal intensity and duration of the intervention to achieve sustained risk reduction in patients at high and very high cardiovascular (CV) risk still need to be established. The aim of this study was to evaluate the impact of general practitioner's (GP's) systematic and planned intervention on total CV risk reduction and a change in individual CV risk factors. MATERIAL AND METHODS: This was a cluster-randomized trial (ISRCTN31857696) including 64 practices and 3245 patients aged ≥40. The participating GPs and their examinees were randomized into an intervention or to a control group (standard care). Intervention group practitioners followed up their examinees during 1, 3, 6, 12, and 18 months. The main outcome measures were change in proportion of patients with low, moderate, high, and very high CV risk, and change in individual CV risk factors from the first to the second registration. RESULTS: The proportion of patients with very high CV risk was lower in the intervention group, the same as of patients with high blood pressure, total and LDL cholesterol, and increased intake of alcohol. The mean systolic (-1.49 mmHg) and diastolic (-1.57 mmHg) blood pressure, triglycerides (-0.18 mmol/L), body mass index (-0.22), and waist (-0.4 cm) and hip circumference (-1.08 cm) was reduced significantly in the intervention group. There was no additional impact in the intervention group of other tested CV risk factors. CONCLUSIONS: Systematic and planned GP's intervention in CVD prevention reduces the number of patients with very high total CV risk and influences a change in lifestyle habits.

Diversity of metabolic syndrome criteria in association with cardiovascular diseases--a family medicine-based investigation.

BACKGROUND: This study compared the association between the 3 definitions of metabolic syndrome (MetS) suggested by the World Health Organization (WHO), National Cholesterol Education Programme (NCEP ATP III), and International Diabetes Federation (IDF), and the risk of cardiovascular diseases (CVD) and shows the prevalence and characteristics of persons with MetS in continental vs. coastal regions and rural vs. urban residence in Croatia. MATERIAL/METHODS: A prospective multicenter study was conducted on 3245 participants≥40 years, who visited general practices from May to July 2008 for any reason. This was a cross-sectional study of the Cardiovascular Risk and Intervention Study in Croatia-family medicine project (ISRCTN31857696). RESULTS: All analyzed MetS definitions showed an association with CVD, but the strongest was shown by NCEP ATP III; coronary disease OR 2.48 (95% CI 1.80-3.82), cerebrovascular disease OR 2.14 (1.19-3.86), and peripheral artery disease OR 1.55 (1.04-2.32), especially for age and male sex. According to the NCEP ATP III (IDF), the prevalence was 38.7% (45.9%) [15.9% (18.6%) in men, and 22.7% (27.3%) in women, and 28.4% (33.9%) in the continental region, 10.2% (10.9%) in the coastal region, 26.2% (31.5%) in urban areas, and 12.4% (14.4%) in rural areas. Older age, male sex, and residence in the continental area were positively associated with MetS diagnosis according to NCEP ATP III, and current smoking and Mediterranean diet adherence have protective effects. CONCLUSIONS: The NCEP ATP III definition seems to provide the strongest association with CVD and should therefore be preferred for use in this population.

How well do anthropometric indices correlate with cardiovascular risk factors? A cross-sectional study in Croati.

BACKGROUND: Usefulness of anthropometric indices (AI) as predictors of CV risk is unclear and remains controversial. MATERIAL/METHODS: To evaluate the correlation between AI and CV risk factors in the Croatian adult population and to observe possible differences between coastal and inland regions and urban and rural settlements. CRISIC-fm (ISRCTN31857696) is a prospective, randomized cohort study conducted in GP (general practitioner) practices in Croatia. Between May and July 2008, 59 GPs each recruited 55 participants aged ≥ 40 years, who visited a practice for any reason. Height, weight, waist and hip circumference and blood pressure were measured. Blood samples were analyzed in accredited laboratories. RESULTS: Out of 2467 participants (61.9% women, 38.1% men), 36.3% were obese, with fewer in coastal than inland areas. More obese people were in rural areas. Logistic regression showed BMI was the most important predictor of hypertension, diabetes and dyslipidemia in both regions (except for diabetes in the coastal area), and for urban and rural settlements (except for diabetes in rural areas). WtHR was a significant predictor for hypertension and dyslipidemia in the coastal (but only for hypertension in the inland area), and in urban settlements (in rural only for hypertension). None of the AI showed significant correlation with total CV risk, but WC and BMI did with stroke risk. Receiver operating curve (ROC) analyses showed that WtHR was a better predictor than all other AI for hypertension and dyslipidemia. CONCLUSIONS: Results encourage the use of BMI and WtHR as important tools in predicting CV risk in GP's practice.

Continental-Mediterranean and rural-urban differences in cardiovascular risk factors in Croatian population.

AIM: To compare the distribution of cardiovascular disease (CVD) factors between continental and Mediterranean areas and urban and rural areas of Croatia, as well as to investigate the differences in achieving treatment goals by the general practitioners (GP) in different settings. METHODS: A multicenter prospective study was performed on 2467 participants of both sexes ≥40 years old, who visited for any reason 59 general practices covering the whole area of Croatia (May-July 2008). The study was a part of the Cardiovascular Risk and Intervention Study in Croatia-family medicine (CRISIC-fm) study. Patients were interviewed using a 140-item questionnaire on socio-demographics and CVD risk factors. We measured body mass index (BMI) and waist circumference and determined biochemical variables including blood pressure, total, high-density lipoprotein-, and low-density lipoprotein-cholesterol, triglycerides, glycemia, and uric acid. RESULTS: Participants from continental rural areas had significantly higher systolic and diastolic blood pressure (P<0.001), obesity (P=0.001), increased waist circumference (P<0.001), and more intense physical activity (P=0.020). Participants from coastal rural areas had higher HDL-cholesterol, participants from continental rural and coastal urban areas had higher LDL-cholesterol, and participants from rural continental had significantly higher BMI and waist circumference. CONCLUSION: Prevalence of CVD risk factors in Croatian population is high. Greater burden of risk factors in continental region and rural areas may be partly explained by lifestyle differences.

[Diet as a cardiovascular risk factor in family medicine]. / Prehrana kao rizicni cimbenik kardiovaskularnih bolesti u obiteljskoj medicini.

Although Mediterranean country by its geographic position, according to cardiovascular mortality (CVM) rate, Croatia belongs to Central-East European countries with high CV mortality. Prevention by changing nutritional habits is population (public health programmes) or individually targeted. General practitioner (GP) provides care for whole person in its environment and GP's team plays a key role in achieving lifestyle changes. GPs intervention is individually/group/family targeted by counselling or using printed leaflets (individual manner, organized programmes). Adherence to lifestyle changes is not an easy task; it is higher when recommendations are simple and part of individually tailored programme with follow- ups included. Motivation is essential, but obstacles to implementation (by patient and GPs) are also important. Nutritional intervention influences most important CV risk factors: cholesterol level, blood pressure (BP), diabetes. Restriction in total energy intake with additional nutritional interventions is recommended. Lower animal fat intake causes CVM reduction by 12%, taking additional serving of fruit/day by 7% and vegetables by 4%. Restriction of dietary salt intake (3 g/day) lowers BP by 2-8 mm Hg, CVM by 16%. Nutritional intervention gains CHD and stroke redact in healthy adults (12%, 11% respectively). Respecting individual lifestyle and nutrition, GP should suggest both home cooking and careful food declaration reading and discourage salt adding. Recommended daily salt intake is < or =6 g. In BP lowering, salt intake restriction (10-12 to 5-6 g/day) is as efficient as taking one antihypertensive drug. Lifestyle intervention targeting nutritional habits and pharmacotherapy is the most efficient combination in CV risk factors control.